Prior Authorization Guide

What Is Prior Authorization?

Prior authorization (PA) is approval from DentaQuest that must be obtained before certain dental procedures are performed. Your dentist's office handles the submission; you don't need to do it yourself.

Services Requiring Prior Authorization

  • Crowns (caps)
  • Partial dentures
  • Complete dentures
  • Periodontal scaling
  • Other procedures as listed in the Office Reference Manual

How the Process Works

  1. Your dentist examines you and determines you need a procedure requiring PA
  2. The dental office submits a PA request to DentaQuest with:
    • X-rays and/or photos
    • Clinical notes documenting medical necessity
    • The specific CDT procedure code(s)
  3. DentaQuest's clinical review team evaluates the request
  4. DentaQuest issues an approval or denial (typically 5-15 business days)
  5. If approved: your dentist schedules the procedure
  6. If denied: you and your dentist can appeal

Critical Rule

Treatment started before PA approval is at the financial risk of the dental office. Non-emergent treatment performed without authorization may not be covered. Always wait for confirmation.

If Your PA Is Denied

Step 1: Understand the Reason

DentaQuest must provide a written explanation for any denial. Common reasons include:

  • Frequency limit not met (e.g., crown was done within past 7 years)
  • Clinical criteria not met (insufficient documentation)
  • Service not a covered benefit

Step 2: Appeal

You have the right to appeal any denial. Two paths:

Provider Appeal: Your dentist submits additional clinical documentation supporting medical necessity. This is often the most effective route.

Member Appeal: You can file an appeal directly with DentaQuest:

Step 3: State Fair Hearing

If your appeal is denied, you can request a State Fair Hearing through Health First Colorado. This is an independent review by an administrative law judge.

Contact: Health First Colorado Member Contact Center at 800-221-3943

Tips for Getting Approvals

  • Make sure your dentist provides thorough clinical documentation
  • Include current X-rays showing the clinical need
  • Reference specific clinical criteria from DentaQuest's guidelines
  • If the initial request is denied, ask your dentist what additional documentation might help on appeal
  • Be persistent — many initial denials are overturned on appeal with better documentation

See also: Coverage Summary | Procedures/Crowns on Implant Stems | Action Items